- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,268.43 / $8,014.43 / $12,383.90
| Facility | | $4,268.43 | $8,014.43 | $12,383.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,908.84 / $3,374.26 / $4,149.95
| Professional | | $2,908.84 | $3,374.26 | $4,149.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,848.06 / $4,848.06 / $4,848.06
| Professional | | $4,848.06 | $4,848.06 | $4,848.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,428.55 / $6,352.89 / $7,852.88
| Facility | | $3,428.55 | $6,352.89 | $7,852.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,102.76 / $3,878.45 / $5,217.72
| Facility | | $3,102.76 | $3,878.45 | $5,217.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,628.95 / $2,327.07 / $19,314.68
| Professional | | $1,628.95 | $2,327.07 | $19,314.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,628.95 / $2,327.07 / $5,817.68
| Professional | | $1,628.95 | $2,327.07 | $5,817.68 |